Association between radioulnar impingement and salvage surgical procedures of the distal radioulnar joint: influence of confounding variables.

We conducted an ambispective cohort study to assess the association between symptomatic radioulnar impingement syndrome (SRUIS) and distal radioulnar joint (DRUJ) salvage surgery to examine the influence of confounders on the final effect. The outcome variable was the incidence of SRUIS and the exposure variable was the surgical procedure. Seventy-two patients with median age of 48 years (IQR 25-78) were examined using bivariate and logistic regression multivariate analyses, and confounders were analysed in 15 multivariate models. Overall, SRUIS occurred in 21 patients (29%). Bivariate analysis showed a significant association between SRUIS and type of surgical procedure, observed in 71% after Sauvé-Kapandji, 50% after Bowers and 15% after Darrach procedure. When adjusted for age, aetiology and previous surgery, the significant association disappeared. Confounding is an important factor when accounting for SRUIS after DRUJ salvage surgery. The risk of SRUIS did not depend on the procedure, but rather on patient's age, aetiology and previous surgery.Level of evidence: II.

A Meta-Analysis of the Outcomes of Ligament Reconstruction Compared to No Reconstruction with or without Tendon Interposition Following Trapeziectomy for Thumb Carpometacarpal Joint Osteoarthritis.

Background: The outcomes of trapeziectomy with ligament reconstruction and tendon interposition (LRTI) compared to the trapeziectomy (T) alone or in combination with tendon interposition (TIA) in the treatment of osteoarthritis (OA) of the carpometacarpal joint (CMCJ) of the thumb are still debated. The aim of this study is to conduct a meta-analysis to determine whether the outcomes of LRTI were better compared to T or TIA. Methods: A meta-analysis of randomised trials that included the outcomes of patients with thumb CMCJ OA that underwent LRTI, T or TIA with at least 1 year follow-up. The outcomes included number of patients with pain 1 year after surgery (NPP), Visual Analog Scale for Pain (VAS Pain), key pinch strength, patient reported outcome measurements (PROMs) and number of adverse effect (AEs). The effect was assessed using mean difference for quantitative variables (VAS pain and key pinch), standardised mean difference for PROMs and relative risk for binary variables (NPP and AEs). Results: Seven studies met the inclusion criteria (857 participants: 438 LRTI vs 419 T/TIA). We did not find significant differences between LRTI and T/TIA in NPP, VAS pain, key pinch at 1 year and 5 years or more, PROMs, and AEs at 1 year and at 5 years or more after surgery. Conclusions: The outcomes of LRTI are not superior to T or TIA in the treatment of OA of the thumb CMCJ. Level of Evidence: Level I (Therapeutic).

Measuring symptoms severity in carpal tunnel syndrome: score agreement and responsiveness of the Atroshi-Lyrén 6-item symptoms scale and the Boston symptom severity scale.

PURPOSE: To assess score agreement between the Atroshi-Lyrén 6-item symptoms scale and the Boston 11-item symptom severity scale and compare their responsiveness in patients with carpal tunnel syndrome before and after carpal tunnel release surgery. METHODS: This prospective cohort study included 3 cohorts that completed the A-L and Boston scales (conventional score 1-5) on the same occasion: a preoperative and short-term postoperative cohort (212 patients), a mid-term postoperative cohort (101 patients), and a long-term postoperative cohort (124 patients). Agreement was assessed with Lin's concordance correlation coefficient and Passing-Bablok regression analysis. Analyses using item response theory were conducted on responses from the preoperative/short-term postoperative cohort including testing of item infit/outfit. Reliability was assessed with Cronbach alpha. Overall and sex-specific effect sizes were calculated using Cohen's d. RESULTS: Lin's CCCs were high (0.81-0.91). Passing-Bablok analysis showed constant and proportional differences in all cohorts except preoperative to short-term postoperative change. Both scales showed high reliability (alpha, 0.88-0.93). The IRT-based analyses showed infit/outfit values within the desired range. With IRT-based scoring, the A-L scale had significantly higher responsiveness than the Boston scale, overall (d, 2.02 vs 1.59), in women (d, 2.22 vs 1.77) and in men (d, 1.74 vs 1.36). CONCLUSION: The Atroshi-Lyrén 6-item symptoms scale and the Boston 11-item symptom severity scale show good agreement but are not equivalent in measuring CTS-related symptoms severity. When using IRT-based scoring, the Atroshi-Lyrén scale demonstrated significantly higher responsiveness.

Survival analysis and influence of the surgical aggression of a cohort of orthopedic and trauma patients in a non-controlled spread COVID-19 scenario.

BACKGROUND: Determining the infection rate and mortality probability in healthy patients who have undergone orthopedic and trauma surgeries (OTS) during a period of uncontrolled COVID-19 transmission may help to inform preparations for future waves. This study performed a survival analysis in a cohort of non-infected OTS patients and determined the effect of COVID-19 on mortality. METHODS: This observational study included 184 patients who underwent OTS in the month before surgical activities ceased and before the implementation of special measures. Four groups of surgery (GS) were established based on the location of the surgery and the grade of inflammation produced. Crude risk of infection and infection rates were assessed. Survival and failure functions by GS were analyzed. Comparison of the Kaplan-Meier survival curves by GS was assessed. Cox regression and Fine-Gray models were used to determine the effect of different confounders on mortality. RESULTS: The crude risk of COVID-19 diagnosis was 14.13% (95% CI: 9.83-19.90%). The total incidence rate was 2.67 (1000 person-days, 95% CI: 1.74-3.91). At the end of follow-up, there was a 94.42% chance of surviving 76 days or more after OTS. The differences in K-M survivor curves by GS indicated that GS 4 presented a lower survival function (Mantel-Cox test, p = 0.024; Wilcoxon-Breslow test, p = 0.044; Tarone-Ware test, p = 0.032). One of the best models to determine the association with mortality was the age-adjusted model for GS, high blood pressure, and respiratory history, with a hazard ratio of 1.112 in Cox regression analysis (95% CI: 1.005-1.230) and a sub hazard ratio of 1.111 (95% CI: 1.046-1.177) in Fine-Gray regression analysis for competitive risk. CONCLUSIONS: The infection risk after OTS was similar to that of the general population in a community transmission area; the grade of surgical aggression did not influence this rate. The survival probability was extremely high if patients had not previously been infected. With higher grades of surgical aggression, the risk of mortality was higher in OTS patients. Adjusting for age and other confounders (e.g., GS, high blood pressure and respiratory history) was associated with higher mortality rates.

The methodological requirements for clinical examination and patient-reported outcomes, and how to test them.

This article presents the methodological requirements for clinical examination and patient-reported outcomes measurements. The assessment of any measurement for clinical research in hand surgery is difficult. A method of measuring a criterion could be 100% reliable but 100% invalid. Bias may be present in our assessment if we do not take into account the methodological requirements related to reliability, validity, and responsiveness of our measures. Reliability refers to intra-observer agreement, inter-observer agreement, or agreement between two methods of assessment, and, for patient-reported measures, internal consistency and test-retest reliability. Validity is the capability of a clinical method to measure what it proposes to measure. Assessing validity involves comparing a measure with one or more other measures, and, if possible, with a reference standard criterion. Responsiveness is the ability to detect important clinical change. The Consensus-based Standards for the Selection of Health Measurement Instruments provides the standards required for design and recommended statistical analyses of patient-reported outcome measures.

A biomechanical comparison of the modified Bunnell pullout and Teo intraosseous suture techniques for attachment of tendon to bone.

We compared the biomechanical properties of the Teo intraosseous suture technique with the modified Bunnell pullout technique in a cadaver model after a tendon to bone repair. Thirty-six fresh-frozen cadaveric fingers were assigned randomly to three groups (Teo, Bunnell and control groups). They were loaded cyclically from 2 to 15 N at 25 mm/min, for 500 cycles. Gap formation at the repair site was assessed every 100 cycles and then specimens were tested to failure. The Teo group had an approximately 30% smaller gap every 100 cycles and needed 30% more energy to obtain a 2 mm gap than the modified Bunnell group. Displacement after 500 cyclic loads was significantly lower in the Teo group than in the Bunnell group. For the failure of the Teo suture, it was necessary to apply 31% more load than the Bunnell technique.

The Spanish version of the Patient-Rated Wrist Evaluation outcome measure: cross-cultural adaptation process, reliability, measurement error and construct validity.

BACKGROUND: The Patient-Rated Wrist Evaluation (PRWE) is a widely used measure of patient-reported disability and pain related to wrist disorders. We performed cross-cultural adaptation of the PRWE into Spanish (Spain) and assessed reliability and construct validity in patients with distal radius fracture. METHODS: Adaptation of the English version to Spanish (Spain) was performed using translation/back translation methodology. The measurement properties of the PRWE-Spanish were assessed in a sample of 40 consecutive patients (31 women), mean age 58 (SD 19) years, with extra-articular distal radius fractures treated with closed reduction and cast. The patients completed the PRWE-Spanish and the standard Spanish versions of the 11-item Disabilities of the Arm, Shoulder and Hand (QuickDASH) and EQ-5D questionnaires at baseline (health status before fracture) and at 8, 9, 12, and 13 weeks after treatment. Internal-consistency reliability was assessed with the Cronbach alpha coefficient and test-retest reliability with the intraclass correlation coefficient (ICC) comparing responses at 8 and 9 weeks and responses at 12 and 13 weeks. Cross-sectional precision was analyzed with the Standard Error of the Measurement (SEM). Longitudinal precision for test-retest reliability coefficient was analyzed with the Standard Error of the Measurement difference (SEMdiff) and the Minimal Detectable Change at 90% (MDC90) and 95% (MDC95) confidence levels. For assessing construct validity we hypothesized that the PRWE-Spanish (lower score indicates less disability and pain) would have strong positive correlation with the QuickDASH (lower score indicates less disability) and moderate negative correlation with the EQ-5D Index (higher score indicates better health); Spearman correlation coefficient (r) was used. RESULTS: For the PRWE total score, Cronbach alpha was 0.98 (SEM = 2.67) at baseline and 0.96 (SEM = 4.37) at 8 weeks. For test-retest reliability ICC was 0.94 (8 and 9 weeks) and 0.96 (12 and 13 weeks) with SEMdiff 7.61 and 6.18 and MDC95 13.74 and 12.11, respectively. The PRWE-Spanish scores had strong positive correlation with the QuickDASH scores at baseline (r = 0.71) and at 8 weeks (r = 0.79) and moderate negative correlation with the EQ-5D Index (r = -0.44 and r = -0.40, respectively). CONCLUSIONS: The PRWE-Spanish showed high internal-consistency and test-retest reliability and good construct validity in patients with distal radius fracture.

Reliability and construct validity of the Spanish version of the 6-item CTS symptoms scale for outcomes assessment in carpal tunnel syndrome.

BACKGROUND: The purpose of this study was to assess the reliability and construct validity of the Spanish version of the 6-item carpal tunnel syndrome (CTS) symptoms scale (CTS-6). METHODS: In this cross-sectional study 40 patients diagnosed with CTS based on clinical and neurophysiologic criteria, completed the standard Spanish versions of the CTS-6 and the disabilities of the arm, shoulder and hand (QuickDASH) scales on two occasions with a 1-week interval. Internal-consistency reliability was assessed with the Cronbach alpha coefficient and test-retest reliability with the intraclass correlation coefficient, two way random effect model and absolute agreement definition (ICC2,1). Cross-sectional precision was analyzed with the Standard Error of the Measurement (SEM). Longitudinal precision for test-retest reliability coefficient was assessed with the Standard Error of the Measurement difference (SEMdiff) and the Minimal Detectable Change at 95 % confidence level (MDC95). For assessing construct validity it was hypothesized that the CTS-6 would have a strong positive correlation with the QuickDASH, analyzed with the Pearson correlation coefficient (r). RESULTS: The standard Spanish version of the CTS-6 presented a Cronbach alpha of 0.81 with a SEM of 0.3. Test-retest reliability showed an ICC of 0.85 with a SRMdiff of 0.36 and a MDC95 of 0.7. The correlation between CTS-6 and the QuickDASH was concordant with the a priori formulated construct hypothesis (r 0.69) CONCLUSIONS: The standard Spanish version of the 6-item CTS symptoms scale showed good internal consistency, test-retest reliability and construct validity for outcomes assessment in CTS. The CTS-6 will be useful to clinicians and researchers in Spanish speaking parts of the world. The use of standardized outcome measures across countries also will facilitate comparison of research results in carpal tunnel syndrome.

Intervention randomized controlled trials involving wrist and shoulder arthroscopy: a systematic review.

BACKGROUND: Although arthroscopy of upper extremity joints was initially a diagnostic tool, it is increasingly used for therapeutic interventions. Randomized controlled trials (RCTs) are considered the gold standard for assessing treatment efficacy. We aimed to review the literature for intervention RCTs involving wrist and shoulder arthroscopy. METHODS: We performed a systematic review for RCTs in which at least one arm was an intervention performed through wrist arthroscopy or shoulder arthroscopy. PubMed and Cochrane Library databases were searched up to December 2012. Two researchers reviewed each article and recorded the condition treated, randomization method, number of randomized participants, time of randomization, outcomes measures, blinding, and description of dropouts and withdrawals. We used the modified Jadad scale that considers the randomization method, blinding, and dropouts/withdrawals; score 0 (lowest quality) to 5 (highest quality). The scores for the wrist and shoulder RCTs were compared with the Mann-Whitney test. RESULTS: The first references to both wrist and shoulder arthroscopy appeared in the late 1970s. The search found 4 wrist arthroscopy intervention RCTs (Kienböck's disease, dorsal wrist ganglia, volar wrist ganglia, and distal radius fracture; first 3 compared arthroscopic with open surgery). The median number of participants was 45. The search found 50 shoulder arthroscopy intervention RCTs (rotator cuff tears 22, instability 14, impingement 9, and other conditions 5). Of these, 31 compared different arthroscopic treatments, 12 compared arthroscopic with open treatment, and 7 compared arthroscopic with nonoperative treatment. The median number of participants was 60. The median modified Jadad score for the wrist RCTs was 0.5 (range 0-1) and for the shoulder RCTs 3.0 (range 0-5) (p = 0.012). CONCLUSION: Despite the increasing use of wrist arthroscopy in the treatment of various wrist disorders the efficacy of arthroscopically performed wrist interventions has been studied in only 4 randomized studies compared to 50 randomized studies of significantly higher quality assessing interventions performed through shoulder arthroscopy.

Level of evidence in hand surgery.

BACKGROUND: Few investigations have been done to analyze the level of evidence in journals related to hand surgery, compared to other related research fields. The objective of this study was to assess the level of evidence of the clinical research papers published in the Ibero-american (RICMA), the European (JHSE) and American (JHSA) Journals of Hand Surgery. METHODS: A total of 932 clinical research papers published between 2005 and 2009 (RICMA 60, JHSE 461, and JHSA 411) were reviewed. Two independent observers classified the level of evidence based on the Oxford International Classification, 5 being the lowest level and 1 the highest level. The observed frequencies of the level of evidence for each journal were compared with the expected frequencies by a chi-square (χ 2) test for categorical variables with a significance level of 0.05. RESULTS: Inter-observer agreement analysis showed a Kappa of 0.617. Intra-observer agreement analysis presented a Kappa of 0.66 for the observer 1, and a Kappa of 0.751 for the observer 2. More than 80% of the papers in RICMA and JHSE and a 67.6% in the JHSA presented a level of 4. No level 1 or 2 studies were published in RICMA, compared to JHSE (0.9% level 1 and 5.0% level 2) and JHSA (8.3% level 1 and 10% level 2). The percentage of papers with level 3 published in RICMA (16.7%) was higher compared to the JHSE (11.1%) and the JHSA (14.1%). All the results were statistically significant (χ2=63.945; p<0.001). CONCLUSIONS: The level of evidence in hand surgery is dependent on the type of journal; being the highest level evidence papers those published in the JHSA, followed by the JHSE and finally the RICMA. Knowing the status of the level of evidence published in hand surgery is the starting point to face the challenges of improving the quality of our clinical research.

Epidemiologic associations of carpal tunnel syndrome and sleep position: Is there a case for causation?

INTRODUCTION: Carpal tunnel syndrome (CTS) is thought to be due to compression of the median nerve in the carpal tunnel. It is known that carpal tunnel pressures are elevated in wrist postures of flexion and extension and in those patients with CTS. Classic symptoms of CTS include night waking with pain, tingling, and numbness. These classic symptoms stimulated our interest in the relationship of sleep to the development of CTS. METHOD: We reviewed the literature surrounding the epidemiology of CTS and the literature regarding sleep disturbances. Through careful distillation of these studies and a process of reasoning, we have developed a hypothesis for a causal mechanism of CTS. RESULTS: Epidemiologically, it has been shown that CTS is associated with age, gender, increased body mass index (BMI), diabetes, pregnancy, and is more common in some populations. The same associations noted above for CTS are strongly associated with sleep disturbances. Sleep disturbances due to age, gender, BMI, pregnancy, and population variations are all associated with sleeping in the lateral position supporting the hypothesis that a common causative mechanism of CTS is sleeping in a lateral position. DISCUSSION: We believe that the epidemiologic associations with CTS act through a common causative mechanism, increased sleeping in the lateral position which puts the wrist at increased risk of flexion or extension, compressing the median nerve in the carpal tunnel. This hypothesis is simple and explains the connection between a previously unconnected group of epidemiologic associations. This realization has real clinical significance in that it focuses our attention on the early disorder when it is completely reversible. It clarifies previously confused clinical circumstances, creates research questions that can be tested, and it invites us to change our clinical perspective in this most common form of nerve compression.

Evaluation of the Spanish version of the DASH and carpal tunnel syndrome health-related quality-of-life instruments: cross-cultural adaptation process and reliability.

The methodologic requirements for cross-national use of specific health outcome instruments in hand surgery are presented. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire as a specific upper-extremity instrument and the Carpal Tunnel Syndrome (CTS) questionnaire as a specific disease instrument were adapted to Spanish for use in international studies. The adaptations were based on translation/back translation methodology. Meetings of translators, researchers, and patients were organized to produce successive versions. A study involving 50 people was carried out to consider the relative value (through a visual analog scale) of each response choice of the questionnaire items. Internal consistency and reproducibility of the Spanish version of both instruments were assessed by self-administering the questionnaires to 42 patients with the diagnosis of CTS on 2 different occasions 1 week apart. The average ratings of equivalence of the translated version with the original were high, regardless of the difficulty of translation. The adaptation process of the DASH and CTS instruments concluded with questionnaires conceptually equivalent to the original and with an acceptable level of reliability.